﻿<!DOCTYPE html>
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
    <title>WEB FORM</title>
    <style type="text/css">
        .auto-style1 {
            width: 160px;
        }
        .auto-style2 {
            width: 160px;
            text-align: center;
        }
    </style>
</head>
<body>
    <form action="aply-now.php" method="get">        
            <table border="1">
                <tr>
                    <td align="right" class="auto-style1"><label for="lname"><strong>Last Name</strong></label></td>
                    <td> <input type="text" style="width:300px;" name="lname" id="lname" placeholder="Dakov" /></td>
                </tr>
                <tr>
                    <td align="right" class="auto-style1"><label for="fname"><strong>First Name</strong></label></td>
                    <td><input type="text" style="width:300px;" name="fname" placeholder="Todor" /></td>
                </tr>
                <tr>
                    <td align="right" class="auto-style1"><label for="adress"><strong>Adress</strong></label></td>
                    <td><input type="text"
                    placeholder="17 Hristo Botev Str. floor 3, ap.12"
                    cols="5" rows="5" style="width:300px; height:50px;" name="adress" id="adress" value=""></td>
                </tr>
                <tr>
                    <td align="right" class="auto-style1"><label for="city"><strong>City</strong></label></td>
                    <td><input type="text" placeholder="Plovdiv" style="width:250px;" name="city" id="city" value="">
                    <label for="state"><strong>State</strong></label>
                    <input type="text" style="width:50px;" name="state" id="state"/></td>
                </tr>
                <tr>
                    <td align="right" class="auto-style1"><label for="zip"><strong>Zip/Postal Code</strong></label></td>
                    <td><input type="text" placeholder="4000" style="width:50px;" name="zip" id="zip"/></td>
                </tr>
                <tr>
                    <td align="right" class="auto-style1"><label for="country"><strong>Country</strong></label></td>
                    <td><select name="country" style="width:250px">
                          <option value="Value 1" selected="selected">Bulgaria</option>
                          <option value="Value 2">Russia</option>
                          <option value="Value 3">USA</option>
                        </select>
                        </td>
                </tr>
                <tr>
                    <td align="right" class="auto-style1"><label for="tel"><strong>Phone(country code, area code, number)</strong></label></td>
                    <td>(+<input type="tel" placeholder="359" style="width:50px;" name="tel" id="tel"/>)
                        <input type="tel" placeholder="88" style="width:50px;"name="tel1"  />-
                        <input type="tel" placeholder="8334343" style="width:160px;"name="tel2"  />
                    </td>
                </tr>
                <tr>
                    <td align="right" class="auto-style1"><label for="email"><strong>E-mail</strong></label></td>
                    <td><input type="email" placeholder="tdd@dekom.bg" style="width:300px;" name="email" id="email"/></td>
                </tr>
                <tr>
                    <td align="right" class="auto-style1"><label><strong>Birth date</strong></label></td>
                    <td><label for="month">Month</label>
                        <input type="text"placeholder="06" style="width:20px;" name="month" id="month"/>
                        <label for="day">Day</label>
                        <input type="text" placeholder="14" style="width:20px;" name="day" id="day"/>
                        <label for="yard">Yard(4digi)</label>
                        <input type="text" placeholder="1980" style="width:100px;" name="yard" id="yard"/>
                    </td>
                </tr>
                 <tr>
                    <td align="right" class="auto-style1"><label for="gender"><strong>Gender</strong></label></td>
                    <td><select name="gender" style="width:65px">
                          <option value="Value 1" selected="selected">Male</option>
                          <option value="Value 2">Famale</option>                          
                        </select>
                        </td>
                </tr>
                <tr>
                    <td align="right" class="auto-style1"><label><strong>Starting date</strong></label></td>
                    <td>
                        <input type="radio" name="start" id="start"/>
                        <label for="start">Sping 2006</label>
                        <input type="radio" name="start" id="start1"/>
                        <label for="start1">Summer 2006</label>
                    </td>
                </tr>
                 <tr>
                    <td align="right" class="auto-style1"><label for="comment"><strong>Commentars/Questions</strong></label></td>
                    <td><textarea style="width:300px; height:100px">Please send me more information about the lodging.</textarea></td>
                </tr>
                <tr>
                    <td class="auto-style2" colspan="2" >
                        <input type="submit" style="width:100px; background-color:#ebe3b5;" name="submit" value="Submit " />
                        <input type="reset" style="width:120px; background-color:#ebe3b5;" name="reset" value="Clear This Form " />
                    </td>
                </tr>
            </table>          
    </form>
</body>
</html>
